December 2008  
Volume 24, Number 14  

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Dear Medicaid Provider,

Welcome to the December 2008 edition of the Medicaid Update. This month's issue features articles on new hospital outpatient rates and increases in practitioner fees and payment enhancements. You will also find important policy bulletins and pharmacy updates.

We continually look for additional ways to keep you up to informed. If you have any ideas or comments about this publication, please e-mail us: medicaidupdate@health.state.ny.us.

The New York State Department of Health would like to wish your and your staff a healthy and happy New Year.

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In this issue....

Policy and Billing Guidance

Update - APGs Approved by Centers for Medicare and Medicaid Services.
Increases in Practitioner Fees and Payment Enhancements
2009 Healthcare Common Procedure Coding System is released
Explanation of Medicare Benefits (EOMB)
2009 Ambulette Survey Due
Medical Request for Home Care Form (M11q) Revised
Subcontracting with Another Ambulette Provider Acceptable vs. Unacceptable Practice
Certified Asthma and Diabetes Educators
New Beneficiary-Specific Utilization Thresholds

Policy And Billing Guidance

Payment Error Measurement Rate (PERM) Program
CFC - Propelled Albuterol Inhalers no longer Available By Years End

PHARMACY NEWS

2009 Medicare Prescription Drug Plan Listing
Preferred Drug Program News
Billing instructions for physician administered drugs (J-codes) submitted on electronic claims
Billing instructions for physician administered drugs (J-codes) submitted on paper claims

NEWS FOR ALL PROVIDERS

Important Change with Issuance of IRS Form 1099
Smoking Cessation
Provider Services

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Start the New Year Organized

Providers are responsible for notifying Medicaid of any change of address, telephone number, or other pertinent information within 15 days of the change.

Computer Sciences Corporation (CSC), distributes provider checks and paper remittances using the Pay-To Address on file. Other mail including important updates is directed to the Correspondence Address on file for providers.

You may be missing out on important notifications if your address on file is outdated. Occasionally, CSC provider representatives will need to contact a provider by telephone with important information that may impact claims processing and payment.

To verify the contact information on file with CSC, please contact the Call Center at (800) 343-9000.

To update your address and telephone information, follow the instructions below for printing the appropriate form. If you do not have internet access, the Call Center can provide you with a copy of the form.

The Change of Address form must contain the original signature of the provider. Please do not use white out, red ink or double-sided forms.

Fee-for-Service providers (such as practitioners, DME, laboratories, etc.) can obtain more information on where to direct address change requests by visiting: http://www.emedny.org/info/ProviderEnrollment/Provider Maintenance Forms/6101-Address Change 20Form.pdf

Rate-based (Institutional) providers can obtain more information on where to direct address change requests by visiting: http://www.emedny.org/info/ProviderEnrollment/Provider Maintenance Forms/6106-Rate Based Change of Address Form.pdf

Questions? Contact the CSC Call Center at (800) 343-9000.

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APG Bulletin Update

This is to advise you that the federal Centers for Medicare and Medicaid Services (CMS) approved the new Ambulatory Patient Group (APG) payment methodology for hospital-based outpatient services with an effective date of December 1, 2008. APGs for hospital outpatient clinic and ambulatory surgery services will be implemented for dates of service on and after December 1, 2008. APGs for hospital emergency departments will be implemented for dates of service on or after January 1, 2009.

To assure a seamless transition to APGS, eMedNY will automatically reprocess applicable paid outpatient clinic or ambulatory surgery claims for dates of service on or after December 1, received prior to January 1, 2009. These claims will be reprocessed as adjustment transactions using the appropriate APG rate codes.

The following steps will be taken to implement the transition to APG payments for hospital outpatient services.

• During the week of December 29, 2008, providers and their vendors will receive an eMedNY-generated letter identifying their new APG rate codes. A list of the APG rate codes and a list of rate codes subsumed into APGs are now available on the Department of Health's Website at: http://www.health.state.ny.us/health_care/medicaid/rates/apg/index.htm
• Providers that are ready to submit outpatient department and ambulatory surgery unit APG rate codes may begin to do so on December 23, 2008. There is no need to wait to receive the above-noted letter.
• On January 1, 2009, the Department of Health will end-date the current outpatient department, ambulatory surgery, and emergency department rate codes to be subsumed by APGs. The end- date will be December 1, 2008 for outpatient department and ambulatory surgery unit rate codes, and January 1, 2009, for emergency department rate codes.
• All hospital outpatient claims received after January 1, 2009, using hospital rate codes subsumed by APGs will be paid $0.00. APG rate codes must be used after January 1, 2009. (The only exception would be for those hospital-based FQHCs that opted to retain their current reimbursement methodology).
• All outpatient clinic and most ambulatory surgery claims received and processed by eMedNY on and before December 31, 2008, for dates of service on or after December 1, 2008, will be reprocessed automatically by eMedNY through the APG grouper/pricer, resulting in an adjustment of payment based on the new APG payment methodology.
• Providers and vendors will not have to resubmit most claims for dates of service between December 1 and December 31, 2008, to receive the retroactive payment adjustment.
• Providers will be required to resubmit ambulatory surgery claims for dates of service on or after December 1, 2008, which involved primary and secondary surgical procedures during the same visit. eMedNY will not automatically reprocess these claims. To receive the correct payment, providers will have to void the 3089 and 3090 rate code claims; and then resubmit a new APG claim which includes the CPT codes for both the primary and the secondary procedures performed during the visit on the same claim. If providers have not performed this function prior to eMedNY's reprocessing of APG claims, eMedNY will void 3089/3090 claims at that time, and providers may re-bill using the APG rate code as stated above.
• Upon receiving payment adjustments, providers and vendors will retain all usual and customary rights, and as such, may choose to readjust the claim with new APG rate codes.

For additional information on APGs see the Department's APG Website at: http://www.health.state.ny.us/health_care/medicaid/rates/apg/index.htm

Questions you may have on APG implementation may be directed as follows:

For Issues/Questions Regarding	Please Contact
General Policy Rates, Weights, Carve Outs, Payment Rules, and Implementation Issues	NYS Department of Health Office of Health Insurance Programs Div. of Financial Planning and Policy (518) 473-2160 apg@health.state.ny.us
Billing Questions, Remittance Questions, Onsite Training re: Billing	Computer Sciences Corporation eMedNY Call Center (800) 343-9000 eMedNYProviderRelations@csc.com
Questions Grouper Software/Pricer, Product Support, 3M HIS Sales	3-M Health Information Systems, Inc. (800) 435-7776 (800) 367-2447 www.3mhis.com

Thank you for your cooperation and patience during this transition process, the Department is confident that this new payment methodology and the associated investment we are making into ambulatory care services will result in better care for Medicaid patients.

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Effective for dates of service on and after January 1, 2009, Medicaid fees for physicians and other practitioners will be indexed to the 2008 Medicare Physician Fee Schedule.

Effective January 1, 2009, to expand access to primary and preventive care services in health professional shortage areas (HPSAs), physician offices that serve Medicaid patients in these areas will receive an additional 10% enhancement to their reimbursement.

Also, effective January 1, 2009, Medicaid will pay an add-on for weekend and after hour appointments.

Consistent with Medicare, there are separate fees for certain procedure codes depending on whether the service was rendered in a provider's office or in a facility. If a provider reports a Place of Service that corresponds to a non-facility setting (e.g. "Office"), he or she will be reimbursed the non-facility fee for that service. Providers that report a Place of Service that corresponds to a facility setting (e.g. "Outpatient Hospital"), will be reimbursed the facility fee for that service.

The facility fee and non-facility fee for each procedure is available for download at http://www.eMedNY.org. Below is a snapshot of the new Medicaid Physician Fee Schedule for commonly billed services.

There are specific fees for the global, professional and technical components of certain services (e.g. radiology services). Professional services will continue to be payable with the use of Modifier-26 and will be reimbursed at 75% of Medicare's professional component fee. The Global fee for these services will be payable without a modifier.

Physician Fees (http://www.emedny.org/ProviderManuals/Physician/index.html)

Effective January 1, 2009, physician fees will be increased on average almost 40% above their current levels. The following chart shows updated fees for commonly billed services:

Procedure Codes	Procedure Description	Clinician Fee Facility Setting		Clinician Fee Non-Facility Setting
		Current	New	Current	New
99213	Office / outpatient visit	$5.00	$21.54	$30.00	$37.41
99214	Office / outpatient visit	$5.00	$33.69	$30.00	$56.18
99232	Subsequent hospital care	$5.00	$26.01	N/A	N/A
99283	Emergency department visit	$6.50	$24.17	N/A	N/A
71010	Chest x-ray (single view)	$10.00	$20.24	$10.00	$20.24
71020	Chest x-ray (two views)	$15.00	$26.29	$15.00	$26.29
90935	Hemodialysis, one evaluation	$7.50	$33.72	$7.50	$40.46
43239	Upper GI endoscopy	$100.00	$100.00	$100.00	$208.53
45378	Diagnostic colonoscopy	$80.00	$102.22	$80.00	$236.36

Nurse Practitioner Fees (http://www.eMedNY.org/ProviderManuals/NursePractitioner/index.html)

Effective January 1, 2009, Nurse Practitioner fees will be increased on average almost 43% above their current levels. The following chart shows updated fees for commonly billed services:

Procedure Codes	Procedure Description	Clinician Fee Facility Setting		Clinician Fee Non-Facility Setting
		Current	New	Current	New
99212	Office / outpatient visit	$5.00	$9.66	$30.00	$19.96
99213	Office / outpatient visit	$5.00	$18.31	$30.00	$31.80
99214	Office / outpatient visit	$5.00	$28.64	$30.00	$47.75
99308	Nursing facility care	$7.00	$20.32	N/A	N/A
99283	Emergency department visit	$6.50	$20.54	N/A	N/A
43760	Change gastrostomy tube	$20.00	$21.20	$20.00	$101.80
12001	Repair superficial wounds	$8.00	$40.25	$8.00	$71.52

Midwife Fees (http://www.eMedNY.org/ProviderManuals/Midwife/index.html)

Effective January 1, 2009, Midwife fees will be increased on average almost 20% above their current levels. The following chart shows updated fees for commonly billed services:

Procedure Codes	Procedure Description	Clinician Fee Facility Setting		Clinician Fee Non-Facility Setting
		Current	New	Current	New
99212	Office / outpatient visit	$5.00	$9.66	$30.00	$19.96
99213	Office / outpatient visit	$5.00	$18.31	$30.00	$31.80
59400	Routine Obstetrical care	$1,037.00	$1,462.64	$1,037.00	$1,462.64
59409	Vaginal Delivery Only	$630.00	$649.38	$630.00	$649.38
58301	Removal of IUD	$36.00	$30.60	$36.00	$49.61
54150	Circumcision	$20.00	$42.69	$20.00	$101.43

Clinical Psychology Fees (http://www.eMedNY.org/ProviderManuals/ClinicalPsych/index.html)

Effective January 1, 2009, Clinical Psychology fees will be increased on average almost 50% above their current levels. The following chart shows updated fees for commonly billed services:

Procedure Codes	Procedure Description	Clinician Fee Facility Setting		Clinician Fee Non-Facility Setting
		Current	New	Current	New
90806	Individual psychotherapy	$36.00	$54.00	$36.00	$54.00
90818	Individual psychotherapy	$36.00	$45.00	$36.00	$53.15
90853	Group psychotherapy	$9.00	$14.54	$9.00	$18.67

Eyeglass Dispensing Fees

Eyeglass dispensing fees will be increased, independent of the Medicare Fee Schedule, as follows:

Procedure Codes	Procedure Description	Clinician Fee Facility Setting		Clinician Fee Non-Facility Setting
		Current	New	Current	New
92340	Fitting of spectacles (monofocal)	$10.00	$15.00	$10.00	$15.00
92341	Fitting of spectacles (bifocal)	$10.00	$15.00	$10.00	$15.00
92342	Fitting of specticles (multifocal)	$15.00	$20.00	$15.00	$20.00
92352	Special spectacles fitting (monofocal)	$10.00	$15.00	$10.00	$15.00
92353	Special spectacles fitting (multifocal)	$15.00	$20.00	$15.00	$20.00
92354	Special spectacles fitting (signel element)	$8.00	$20.00	$8.00	$20.00
92355	Special spectacles fitting (compound system)	$8.00	$20.00	$8.00	$20.00
92370	Repair & adjust spectacles (except aphakia)	$4.00	$7.00	$4.00	$7.00
92371	Repair & adjust spectacles (for aphakia)	$4.00	$7.00	$4.00	$7.00

Increases for other Practitioner Types

The new Hearing Services/Audiology and Vision Care fee schedules (now available for download at (www.eMedNY.org) will be increased on average almost 20% above their current levels.

Indexing to Medicare Fees

New fees will be increased on average more than 40% above their current levels. For most services the non-facility fee has been indexed to 60% of the Medicare Fee Schedule and the facility fee has been indexed to 50% of the Medicare Fee Schedule. For some services, however, the current Medicaid fee may be higher than the indexed Medicare fee. In most of these cases the new fee will be held constant (protected from a decrease) and set to the current Medicaid payment amount. However, fees for some services (e.g. select Evaluation & Management and Radiology services) do decrease.

Providers participating in the following specialty programs will receive the higher of their current enhanced specialty payment or the new fee schedule amount:

SPECIALTY PROGRAM

• Medicaid Obstetric and Maternal Services ("MOMS") Program
• Preferred Physicians and Children ("PPAC") Program
• HIV Specialty Program
• Broome County Fee Enhancement

Health Professional Shortage Area ("HPSA") Physician Enhanced Payment

There will be a 10% enhancement paid to physicians for office-based professional services performed in federally-designated Geographic Primary Care HPSAs.

Zip Code Specific HPSAs:

Providers should access the following Website to determine if they are located in a "zip code specific" Geographic Primary Care HPSA: http://www.cms.hhs.gov/hpsapsaphysicianbonuses/

Scroll to the "Downloads" section and download the file titled: "2009 Primary Care HPSA." When this file has been unzipped, open the excel file titled "HPSA_2009_WEBPC.xls." If the physician's reported zip code matches one of the zip codes in this file the 10% enhancement will be paid automatically by eMedNY.

Non-Zip Code Specific HPSAs:

Offices located in zip codes that are only partially Geographic Primary Care HPSAs will not match the "zip code specific" file above. Instead, these providers should use the following Website to determine the HPSA status of their office's address: http://datawarehouse.hrsa.gov/geoHPSAAdvisor/

After entering their service address into this online tool some physicians will be informed that their office is located in a non-zip code specific Geographic Primary Care HPSA. These physicians should report modifier -AQ on their claims to receive the 10% enhancement because eMedNY will not automatically pay their enhancement.

Expanded 'After Hours' Access

Effective January 1, 2009, an add-on payment is available for visits which are scheduled and occur on evenings, weekends and holidays as defined by the Department of Health. An evening visit is one which is scheduled for and occurs after 6:00 p.m. A weekend visit is one which is scheduled for and occurs on Saturday and Sunday. A holiday visit is one which is scheduled for and occurs on a designated national holiday.

Providers should use the following CPT codes as appropriate:

Procedure Codes	Procedure Description
99050	Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service.
99051	Services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.

These CPT codes are not payable if they are the only CPT procedure(s) listed on the claim. They are reimbursed only when accompanied by a valid CPT code that represents a medical service/procedure.

Questions? Please contact the Bureau of Policy Development and Coverage at (518) 473-2160.

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FEE-FOR-SERVICE PROVIDERS

For billing dates of service on and after January 1, 2009, all health care providers and plans must utilize the 2009 Healthcare Common Procedure Coding System (HCPCS) as released by the federal Centers for Medicare and Medicaid Services.

In December, notification of coding changes (replacement codes) relating to Medicaid covered services will be available on each affected provider manual homepage, provider communication link.

See this link for more information: http://www.emedny.org/providermanuals/index.html

Other available coding resources include:

• HCPCS Level I (CPT-4) procedure codes for practitioners and laboratories can be purchased in hard copy or electronic form through many publishing houses.
• HCPCS Level II (Alpha-Numeric) codes for other medical services are available electronically at: http://www.cms.hhs.gov/HCPCSReleaseCodeSets/
• ICD-9 Diagnosis and Procedure codes (effective 10/1/2008) are available electronically at: www.cms.hhs.gov/icd9providerdiagnosticcodes, and are also available through publishing houses.

HCPCS and ICD-9 codes are not Medicaid specific. Providers must use the current code set when billing any health care payer. New codes will be identified in the 2009 Fee Schedules and Procedure Codes Sections in early 2009.

Questions? Contact Provider Relations and Utilization Management at (800) 342-3005, Option 4.

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Effective January 1, 2009, a copy of the Explanation of Medicare Benefits (EOMB) will be required for reimbursement of Medicare Deductible/Coinsurance amounts due on "Unlisted," "Miscellaneous" or "Not Otherwise Classified" procedures or services (e.g., J9999, 28899, 41899, 99070).

When submitting claims to Computer Sciences Corporation (CSC), please include the EOMB along with your paper claim, regardless of service date. Claims will "pend" for manual review and show edit 00264, Unlisted Services Procedure Code with Medicare Involvement, on your remittance statement. Failure to provide the EOMB will result in denial. Whenever possible, claims should be billed with the same listed procedure code that was used on the Medicare claim. Providers are required to submit claims using the most current procedure coding for the description provided and the date of service billed.

Questions? Please contact the Division of Provider Relations and Utilization Management at (800) 342-3005, option 3, Medical Pended Claims.

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The City of New York Human Resources Administration's Home Care Services Program (HCSP) will introduce a revised "Medical Request for Home Care" form that has been approved by the New York State Department of Health (DOH).

This form is used to request personal care Level I and Level II services and is commonly known as the M11q. The content of the form essentially remains the same.

Form modifications include:

• New NYC HRA logo, page 1;
• Section I- Client Information, page 1: client's name is requested last name, first name format;
• Section II- Medical Status, page 1: ICD Code must be entered next to the primary and secondary diagnosis;
• Section IV- Referrals, page 4: added "Physician Certification Statement" above the physician signature line; and
• added statement: "Signature date must be within 30 days after the medical exam" below physician signature line.

The form will be implemented on December 1, 2008. The HCSP will continue to accept the current M11q form until May 31, 2009. Providers may obtain a copy of the revised (11/08) M11q form by contacting the Home Care Services Program at (212) 360-5030 or (212) 360-5434. Providers are encouraged to reproduce the form for their use.

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IMPORTANT REMINDER

The due date for submission of the survey has been changed. The updated Annual Ambulette Survey form must be returned by February 17, 2009, to:

Certified/Return Receipt mail is suggested. A copy of the form and proof of mailing should be retained for your records. In the event of non-receipt of the form by the Office of the Medicaid Inspector General, this proof will be used to validate compliance.

The Updated Annual Ambulette Survey form will be available on the OMIG webpage under "Provider Compliance."

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AMBULETTE PROVIDERS

Generally, ambulette providers are to deliver transportation services in vehicles owned or leased by the provider, using drivers employed by the provider. The following description illustrates the difference between allowable short-term versus unacceptable long-term subcontracting.

Short Term Subcontracting

Due to mechanical breakdowns or other acute circumstances, transportation providers face times when the number of available vehicles does not meet the need for services.

For example, two vehicles of Provider A are not in service and are being repaired. As illustrated on pages 24-25 of the Transportation Provider Manual, enrolled Provider A may subcontract with or lease vehicles from Provider B if Provider B meets necessary regulatory requirements. Provider A remains the provider of service, and can submit a claim for the services delivered by the drivers/vehicles of Provider B. The license plate of the actual vehicle used and driver license of the actual transporting driver must be reported on subsequent claims.

Effective January 1, 2009, this arrangement is only allowed when using another Medicaid enrolled provider. Subcontracting or leasing with a transportation vendor who is not enrolled, or has been excluded from participation in the Medicaid Program, is not allowed.

To verify whether a potential vendor is enrolled in Medicaid, you may submit a request to the Department via telephone or via e-mail at . MedTrans@health.state.ny.us

Long Term Subcontracting

The practice of Provider A reassigning trips to another transportation vendor, in a long term arrangement with no intent to secure its own vehicles and drivers, is unacceptable. Such a long term arrangement has the potential of bypassing significant safety and financial controls that are fundamental to the integrity of the Medicaid transportation program.

For more detailed information, please see pages 13-14 of the Information for All Providers, General Billing section of the Transportation Provider Manual.

Questions? Please contact the Medicaid Transportation Unit at (518) 408-4825 or via e-mail at MedTrans@health.state.ny.us

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As described in the October 2008 Medicaid Update, on January 1, 2009, New York State Medicaid will cover asthma and diabetes self-management training services (ASMT and DSMT), when services are provided by a New York State licensed, registered, or certified health care professional, who is also certified as an educator by the National Asthma Educator Certification Board (CAE) or the National Certification Board for Diabetes Educators (CDE).

CAEs and CDEs are required to enroll in the New York State Medicaid program as non-billing providers, and must be employed by or contract with an appropriate billing provider. As part of the enrollment process, the entity with whom the educator is employed or contracted must provide proof of employment or a copy of the contract with the certified educator.

CAE and CDE enrollment forms and instructions are now available on-line at: http://www.emedny.org/info/ProviderEnrollment/index.html (Scroll to the bottom left of the page.)

For detailed information regarding asthma and diabetes education services, please see the October 2008 Medicaid Update.

Questions regarding CAE/CDE enrollment? Please contact the Provider Enrollment Unit at (518) 402-7032.

Questions regarding CAE/CDE Services? Please contact the Bureau of Policy Development and Coverage at (518) 473-2160.

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Improving Medicaid Utilization Management

The Office of Health Insurance Programs (OHIP) has been working in collaboration with the State University of New York (SUNY) and a team of scientists and physicians at Stony Brook University to implement changes to the utilization threshold program.

The first program objective, which is nearing completion, is to assign each Medicaid beneficiary with a set of threshold levels for medical office visits, medications, and laboratory tests, based on the beneficiary's specific disease risk.

The new thresholds, which will be implemented the first quarter of 2009, are expected to significantly reduce both the need for and the number of threshold override requests. As part of this overall initiative, the Department of Health (DOH) will implement a Web Portal which will eliminate the need for paper submission of override requests and will streamline access to utilization thresholds information.

This important enhancement will provide real-time access to the status of the Medicaid beneficiary and allow the provider to make direct on-line requests to upgrade service utilization thresholds by entering additional clinical information. Implementation of the Web Portal is anticipated for the summer of 2009.

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Request for Medicaid Provider Documentation

This is a follow-up to the PERM Project articles previously published in the October 2007 and April 2008 Medicaid Updates.

The Centers for Medicare & Medicaid Services (CMS) and their contractors will be sending letters in December 2008 requesting medical documentation in order to review Medicaid claims for the 2008 Federal Fiscal Year.

Please submit the specific medical documents for the patient, as requested in the letters, to the CMS contractor and to the New York State Department of Health (DOH), Office of the Medicaid Inspector General (OMIG) - PERM Project (addresses for both will be provided in the requests for documentation).

If you are contacted, your cooperation and a timely response are requested, as receipt of the documentation is essential to the success of the program. Requests, and subsequent receipt/non- receipt of documentation, will be tracked.

Your timely response will facilitate the PERM program and minimize the need for further follow-up action by the OMIG.

For information on the NYS PERM Project please see page 20 of the OMIG's Work Plan for State Fiscal Year 2008-2009 at: http://www.omig.state.ny.us/data/

Questions? Please contact the PERM Project staff at (518) 486-7153, (518) 408-0533, or (518) 408-0485.

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In accordance with an FDA Final Rule and under the authority of the Clean Air Act of the U.S. Environmental Protection Agency, CFC-propelled albuterol inhalers can no longer be produced, marketed, or sold in the United States after December 31, 2008. Manufacturers have been increasing production of HFA-propelled albuterol inhalers so that sufficient supplies exist to replace the CFC-propelled inhalers.

There are currently three approved HFA propelled albuterol inhalers:*

ProAir HFA Inhalation Aerosol    Proventil HFA Inhalation Aerosol    Ventolin HFA Inhalation Aerosol

The FDA has determined that these three products are not therapeutic equivalents to CFC-propelled albuterol MDIs.

In addition, an HFA-propelled inhaler containing levalbuterol, an enantiomer of albuterol, is available as Xopenex HFA Inhalation Aerosol. Based on the FDA's determination that albuterol CFC-propelled inhalers and albuterol HFA propelled inhalers are not therapeutic equivalents, the NYS Board of Pharmacy has advised that new prescriptions are necessary when transitioning from CFC-propelled albuterol inhalers to HFA-propelled albuterol inhalers.

* For more information on this topic, please access the following link: www.fda.gov/cder/mdi/albuterol.htm.

For the most current New York State Medicaid Preferred Drug List, please see https://newyork.fhsc.com/ or http://www.health.gov or http://www.eMedNY.org

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Below is a list of the 2009 Medicare Prescription Drug Plans available at no cost to persons with both Medicare and New York State Medicaid recipients. Enrollment in other plans may result in monthly premium liability for the beneficiary. Contract information was updated as of October, 2008.

• American Progressive Insurance Co.
  Prescriba Rx Bronze
  Customer Service (800) 978-9500
  Current Members (866) 566-3052
  www.RxPathway.com
• Bravo Health
  Bravo Rx
  Customer Service (800) 723-9209
  Current Members (877) 504-7252
  www.mybravohealth.com
• CIGNA Medicare RX
  Cigna Medicare Rx Plan One
  Customer Service (800) 735-1459
  Current Members (800) 222-6700
  www.cignamedicarerx.com
• GHI Medicare Prescription Drug Plan
  GHI Medicare Prescription Drug Plan
  Customer Service (800) 325-9792
  Current Members (800) 585-5786
  www.ghi.com
• HIP Insurance Company of New York
  HIP Part D New York
  Customer Service (800) 447-9169
  Current Members (800) 447-9169
  www.HIPusa.com
• Medco Medicare Prescription Plan
  Medco Medicare Prescription Plan - Value
  Customer Service (800) 758-3605
  Current Members (800) 758-4570
  www.medcomedicare.com
• RxAmerica
  Advantage Star Plan by RxAmerica
  Customer Service (800) 429-6686
  Current Members (800) 429-6686
  www.Meds4Medicare.com
• SilverScript Insurance Company
  Silver Script Value
  Customer Service (866) 552-6106
  Current Members (866) 235-5660
  www.silverscript.com
• Unicare (Anthem)
  Medicare Rx Rewards Standard
  Customer Service (866) 892-5334
  Current Members (800) 928-6201
  www.unicare.com

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Attention Pharmacists

Clinical Call Center messaging is updated whenever there is a change in the Preferred Drug List. Please be sure to listen for new information. Once you have heard the new messaging, you can bypass it during subsequent calls by following these steps:

Call the pharmacy prior authorization Call Center at (877) 309-9493. Select Option 2 for Pharmacist and then chose one of the following:

• To validate a prior authorization ending with a 'W", press 1
  • Press 1 to bypass messaging and begin entering the prior authorization number

• To validate a prior authorization that does not end with a 'W", press 2
  • Press 1 and then 6 to bypass messaging and begin entering the prior authorization number

• For information or technical assistance with a prior authorization, press 3

Option 9 provides a pharmacy prior authorization program overview and is periodically changed to include specific information to assist providers when requirements change.

Providers may request e-mail notification when there are changes made to the Preferred Drug List (PDL). Requests should be sent to: NYPDPNotices@firsthealth.com

The most current PDL can be found at: https://newyork.fhsc.com or http://www.health.state.ny.us/.

Questions?

For clinical concerns or preferred drug program questions, contact (877) 309-9493.

For billing questions, contact (800) 343-9000.

For Medicaid pharmacy policy and operations questions, contact (518) 486-3209.

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Attention Ordered Ambulatory Providers

The Medicaid Program is required to collect federal rebates on physician administered drugs. Effective December 11, 2008, the following instructions should be followed when electronically billing physician administered drugs on an ordered ambulatory basis.

Ordered ambulatory providers not billing at 340B prices:

• Physician administered drug claims should be submitted using a valid 11 digit NDC, quantity, and units.
• The Health Insurance Portability and Accountability Act (HIPAA) standard code set for NDCs is 11-digits as a 5-4-2 configuration. Therefore, when entering the NDC, a leading zero must be added. Where the zero is added depends upon the configuration of the NDC. NEVER ENTER HYPHENS.

Examples of the NDC and leading zero placements follow:

NDC# Configuration	Correct Leading Zero placement for 5 + 4 + 2 = 11
XXXX XXXX XX 4 + 4 + 2 = 10	0XXXX XXXX XX 5 + 4 + 2 = 11
XXXXX XXX XX 5 + 3 + 2 = 10	XXXXX-0XXX-XX 5 + 4 + 2 = 11
XXXXX XXXX X 5 + 4 + 1 = 10	XXXXX XXXX 0X 5 + 4 + 2 = 11

• Existing physician administered drug reporting requirements (using the Healthcare Common Procedure Coding
• System - HCPCS) remain the same. Payment will continue to be based on HCPCS reporting information.
• Claims billed on or after December 11, 2008, will be denied if NDC information is not included on the claim.
• Medicaid will edit claims to assure that the labeler/vendor is a participating rebate signer.
• A listing of the drug labeler/vendors that participate in the Medicaid Drug Rebate Program is available at the Website below. Please note that the first 5 digits of the NDC code represent the labeler/vendor. If the labeler code is not on this list, the labeler's drug is not reimbursable by Medicaid.
  http://www.cms.hhs.gov/MedicaidDrugRebateProgram/10_DrugComContactInfo.asp

Ordered ambulatory providers billing Medicaid at 340B prices:

• Enter a value of UD in the product service qualifier-loop 2400, SV2 segment, data element SV202-3 through SV202-6 on the 837I electronic format to identify the drug as a 340B purchased drug.
• When using this option, the 340B price must be billed to Medicaid. It is not necessary to enter the NDC information.

Billing questions can be directed to the eMedNY Call Center at (800) 343-9000.

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Physicians, Nurse Practitioners, Licensed Midwives, Ordered Ambulatory Providers

The Medicaid Program is required to collect federal rebates on physician administered drugs (J-codes). To identify the drug for rebate purposes, the National Drug Code (NDC) information must be present on the claim.

Effective January 29, 2009, the new claim form, eMedNY 150002, must be used when billing physician administered drugs by paper claim. Claim form, eMedNY 150002, must also be used when submitting physician administered drug paper claims or paper claim adjustments for dates of service on or after January 1, 2008.

The new form has been updated with the following fields which must be completed in addition to the CPT/HCPCS fields:

• Field 20: NDC (found on the drug invoice or product package)
• Field 20A: NDC Unit (of measure).
• Field 20B: NDC Quantity
• Field 20C: Total Cost

Billing instructions:

1. The Health Insurance Portability and Accountability Act (HIPAA) standard code set for NDCs is 11-digits as a 5-4-2 configuration. Therefore, when entering the NDC on the claim, a leading zero must be added. Where the zero is added depends upon the configuration of the NDC. NEVER ENTER HYPHENS.
   

   Examples of the NDC and leading zero placements follow:

   NDC# Configuration	Correct Leading Zero placement for 5 + 4 + 2 = 11
   XXXX XXXX XX 4 + 4 + 2 = 10	0XXXX XXXX XX 5 + 4 + 2 = 11
   XXXXX XXX XX 5 + 3 + 2 = 10	XXXXX-0XXX-XX 5 + 4 + 2 = 11
   XXXXX XXXX X 5 + 4 + 1 = 10	XXXXX XXXX 0X 5 + 4 + 2 = 11

   Existing physician administered drug reporting requirements (using the Healthcare Common Procedure Coding System - HCPCS) remain the same. Payment will continue to be based on HCPCS reporting information.
2. For the drug to be paid, the physician administered drug (J-code) MUST be on the first line, and only the first line, of Field 24C (Procedure CD). If the drug procedure code is reported on subsequent lines of the claim form, the required NDC code information will not be associated with the drug procedure code and the claim will be denied. Other "non-drug" procedure codes must be entered on the line two and below. Multiple drug procedure codes reported for the same date of service must be submitted on separate forms so that the J-code is reported on the first claim line of each claim.
3. When entering information in Field 20B (NDC Quantity) and 20C (Total Cost), you must overwrite the red decimals (already appearing in the field) with black or blue ink.
4. For Medicaid to make payment, the labeler/vendor must be a participating rebate signer. A listing of the drug labeler/vendors that participate in the Medicaid Drug Rebate Program is available at the website below. Please note that the first 5 digits of the NDC code represent the labeler/vendor. If the labeler code is not on this list, the labeler's drug is not reimbursable by Medicaid. http://www.cms.hhs.gov/MedicaidDrugRebateProgram/10_DrugComContactInfo.asp
5. Payment will continue to be based on HCPCS reporting information.
   Ordered ambulatory providers billing Medicaid at 340B prices: Enter a value of UD in fields 24D,E,F or G
   When using this option the 340B price must be billed to Medicaid. It is not necessary to enter the NDC information. A supply of the new claim forms will automatically be issued to any impacted providers in mid January 2009.
   
   If additional eMedNY 150002 forms are needed, please contact the eMedNY Call Center at (800) 343-9000. Questions can also be directed to the eMedNY Call Center at this number.

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Computer Sciences Corporation (CSC), the eMedNY contractor for the Department of Health (DOH), issues IRS (Internal Revenue Service) Form 1099 to providers at the beginning of each year for the previous year's Medicaid payments.

Beginning with 1099 forms issued in January 2009, providers should note that unlike previous years, the 1099s are issued with the individual provider's social security number or for businesses, with the Federal Employer Identification Number (FEIN) registered with NY Medicaid.

As with previous years, please note that the IRS 1099 amount is not based on the date of the checks; rather, it is based on the date the checks were released to providers.

Due to the two-week check lag between the date of the check and the date the check is issued, the IRS 1099 amount will not correspond to the sum of all checks issued for your provider identification number during the calendar year.

The IRS 1099 that will be issued for the year 2008 will include the following:

• Check dated 12/17/07 (Cycle 1582) released on 01/02/2008 through;
• Check dated 12/15/08 (Cycle 1634) released on 12/31/08.

Additionally, in order for group practice providers to direct Medicaid payments to a group identification number and corresponding IRS 1099, providers are reminded that they must submit the group identification number in the appropriate field on the claim (paper or electronic).

Claims that do not have the group identification number entered will cause payment to go to the individual provider and his/her IRS 1099.

Please note that 1099s are not issued to providers whose yearly payments are less than $600.00.

IRS 1099s for the year 2008 will be mailed no later than January 31, 2009.

Questions? Please contact the eMedNY Call Center at (800) 343-9000.

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Missing Issues?
The Medicaid Update, indexed by subject area, can be accessed online at:
http://www.nyhealth.gov/health_care/medicaid/program/update/main.htm

Office of the Medicaid Inspector General: http://www.omig.state.ny.us (518) 473-3782

Questions about an Article?
Each article contains a contact number for further information, questions or comments.

Questions about billing and performing EMEVS transactions?
Please contact eMedNY Call Center at: (800) 343-9000.

Provider Training
To sign up for a provider seminar in your area, please enroll online at:
http://www.emedny.org/training/index.aspx

For individual training requests, call (800) 343-9000 or email: emednyproviderrelations@csc.com

Enrollee Eligibility
Call the Touchtone Telephone Verification System at any of the numbers below:

(800) 997-1111    (800) 225-3040      (800) 394-1234.

Address Change?
Questions should be directed to the eMedNY Call Center at: (800) 343-9000.

Fee-for-Service Providers
A change of address form is available at: http://www.emedny.org/info/ProviderEnrollment/index.html

Rate-Based/Institutional Providers
A change of address form is available at: http://www.emedny.org/info/ProviderEnrollment/index.html

Comments and Suggestions Regarding This Publication?
Please contact the editor, Kelli Kudlack, at: medicaidupdate@health.state.ny.us

Medicaid Update is a monthly publication of the New York State Department of Health containing information regarding the care of those enrolled in the Medicaid Program.